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The World's First Human-To-Human Heart Transplant at Groote Schuur

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The World's First Human-To-Human Heart Transplant at Groote Schuur This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0. GUEST EDITORIAL The world’s first human-to-human heart transplant at Groote Schuur Hospital: 50 years later Fifty years ago, on 3 December 1967, the world’s first human-to-human heart transplant was performed by Dr Christiaan Barnard at Groote Schuur Hospital in Cape Town. This was, and probably will remain, the most publicised medical event of all time, making headlines in nearly every international newspaper, magazine and tabloid within days of the event. The idea of transplanting a heart from one human to another captured the minds and imaginations of the public like no other medical event before or since. The only other iconic event in that era that was equally well publicised was man’s first landing on the moon 18 months later. This medical breakthrough was published in the SAMJ 3 weeks later, towards the end of December 1967, and is one of the most cited articles in this journal. The first heart transplant placed Groote Schuur Hospital, the University of Cape Town and South Africa (SA) firmly on the international medical map. A heart transplant was seen by the public as transplanting the very soul of an individual from one person into another. It provoked tremendous debate, some of it very emotional, around the ethics of transplantation and spurred on the international medical and philosophy community to develop the concept of brain death into law. Many countries took decades to adopt such laws – most notably Japan, which took another 30 years (until 1997) to allow organ transplantation from brain-dead donors. Even today many countries do not accept brain death, preventing organ transplantation as a therapeutic option for end-stage heart failure. This tremendous publicity generated by the first heart transplant occurred despite kidney and liver transplantation having preceded heart transplantation by many years. These prior surgical innovations were instrumental in paving the The cover of theSAMJ of 30 December 1976, signed by the members of the way for immunosuppression, vital for modifying the recipient heart transplant team. From the top in a clockwise direction, the signatures immune response and preventing rejection from a genetically are those of Prof. Chris Barnard, Prof. Val Schrire (cardiologist and head non-identical donor. The suppression of host rejection as well as of the cardiac clinic at Groote Schuur Hospital/University of Cape Town), the prevention and treatment of subsequent side-effects remains Dr M C Botha (haematologist/immunologist), Dr Terry O’Donovan (surgeon), the biggest challenge in organ transplantation. Dr S C Bosman (surgeon), Dr Joe (Oz) Ozinsky (anaesthetist), Dr Rodney Ultimately, the goal of a transplant is to improve both length and Hewitson (senior surgeon), and Dr Coert Venter (junior surgeon in training). quality of life when medication and conventional cardiac surgery will Two key articles from the issue are reprinted in the following pages. not adequately alleviate symptoms of heart failure. As far as possible, transplant teams strive to help the recipient lead a life similar in quality to Progress in postoperative critical care has significantly improved early that of his or her peers, unconstrained by the limitations of heart failure. outcomes of heart transplantation, and patients without complications The operation itself as performed today has changed very little are discharged from the intensive care unit in 4 days or less. In the past since Dr Norman Shumway of Stanford University in the USA first year Groote Schuur Hospital has instituted a long-term extracorporeal described the technique in animals in the early 1960s. Small technical membrane oxygenation (ECMO) service, which brings the unit in line variations, the use of heart-preservation solutions (cardioplegia), with international standards for postoperative care in complicated cases. and improvements in the heart-lung machine have optimised this Approximately 15 years after the first heart transplant, in the procedure through the decades. The lack of donors has also been early 1980s a ‘miracle’ drug called cyclosporine was discovered by offset by the use of implantable mechanical assist devices (miniature Jean Borel, earning him a Nobel Prize. This drug was a significant pumps that help the heart), and even a totally artificial heart, as a breakthrough in the management of donor organ rejection, and bridge to transplantation, as well as the recent use of donors whose transformed transplantation from an experimental operation in hearts have stopped (donation after circulatory death: DCD), which leading academic medical centres to standard medical treatment would previously have been deemed unsuitable for transplantation. for end-stage organ failure with reproducible results that could The expensive equipment required to resuscitate these DCD hearts be applied more widely. The numbers of all organ transplants is not available in SA at present, however, and mechanical assist rapidly escalated in the early 1980s, reaching a plateau a decade devices are currently only accessible to patients with excellent later when the availability of donor organs became the major health insurance. In those developed countries that can afford their constraint. Cyclosporine is a member of the class of drugs called extended use, mechanical assist devices are increasingly being used as calcineurin inhibitors (Sandimmun and Neoral are the commercial permanent treatment for heart failure, so-called destination therapy, formulations of the drug), and the other commonly used drug in because of the dearth of donor organs. this class is tacrolimus (Prograft or Advagraft). 3 March 2017, Print edition GUEST EDITORIAL Calcineurin inhibitors are still the mainstay of treatment in organ transplantation, and their use has led to significantly Johan Brink fewer rejection episodes and longer life expectancy. However, Division of Cardiothoracic Surgery, unwanted side-effects are a concern with this more effective Groote Schuur Hospital and Faculty of immunosuppression. Increased incidences of infection, hyper- Health Sciences, University of Cape Town, tension, nephrotoxicity and in some instances long-term renal South Africa failure, diabetes, high cholesterol and cancers are some of the side- [email protected] effects of immunosuppression. The newer immunosuppressive drugs show promise of a reduction in some of these side- effects with or without some calcineurin inhibition, and provide physicians with a larger armamentarium to treat patients. The medical management of heart transplant recipients remains Tim Pennel an ongoing challenge during the period immediately after the Division of Cardiothoracic Surgery, transplant, as well as in the long term. Groote Schuur Hospital and Faculty of Following the significant milestone 50 years ago, the Christiaan Health Sciences, University of Cape Town, Barnard Division of Cardiothoracic Surgery at the University of South Africa Cape Town and Groote Schuur and Red Cross War Memorial Children’s hospitals has transplanted 537 hearts and remains the only heart transplant facility for both indigent and insured patients in SA. Despite the challenges that exist with heart transplantation, the outcome has improved significantly over the past 20 years. The Karen Seele functional status of the recipient after the procedure is generally Division of Cardiothoracic Surgery, excellent, depending on his or her motivation, with an expected 85% Groote Schuur Hospital and Faculty of survival rate at 1 year, decreasing to 75% at 5 years. Health Sciences, University of Cape Town, The Christiaan Barnard Division of Cardiothoracic Surgery is the South Africa proud host of an international celebration to commemorate the 50th anniversary of the world’s first heart transplant, ‘50 years of Heart Transplantation: Courage and Innovation’, on 2 - 4 December 2017 at Groote Schuur Hospital. We hope that the celebration of this courageous and innovative Peter Zilla event will not only encourage further innovations in the management Division of Cardiothoracic Surgery, of heart failure, which constitutes a major burden of disease, but Groote Schuur Hospital and Faculty of also inspire young academics to follow in the footsteps of Christiaan Health Sciences, University of Cape Town, Barnard and his team five decades later. South Africa 4 March 2017, Print edition.
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